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  • Exam Name: Network Management
  • Last Update: May 29, 2024
  • Questions and Answers: 202
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AHM-530 Practice Exam Questions with Answers Network Management Certification

Question # 6

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

A.

the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members

B.

the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies

C.

the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package

D.

all of the above

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Question # 7

The Blanchette Health Plan uses a method of claims submission that allows its providers to submit claims directly to Blanchette through a computer application-to-application exchange of claims using a standard data format. This information indicates that Blanchette allows its providers to submit claims using technology known as

A.

Telemedicine

B.

An electronic referral system

C.

Electronic data interchange

D.

Encounter reporting

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Question # 8

Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health Plan’s organizational committees. The committee reviews cases against providers identified through complaints and grievances or through clinical monitoring activities. If needed, the committee formulates, approves, and monitors corrective action plans for providers. Although Apex administrators and other employees also serve on the committee, only participating providers have voting rights. The committee that Dr. Carmichael serves on is a

A.

Utilization management committee

B.

Peer review committee

C.

Medical advisory committee

D.

Credentialing committee

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Question # 9

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

A.

Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.

B.

It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.

C.

An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.

D.

In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

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Question # 10

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

A.

Allows enrollees to choose from among a greater variety of health plans

B.

Reduces the competition among health plans

C.

Increases the ability of new, local plans to participate in Medicaid programs

D.

Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

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Question # 11

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

A.

A small health plan needs fewer physicians per 1,000 than does a large plan.

B.

A closely managed health plan requires fewer providers than does a loosely managed plan.

C.

Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.

D.

Medicare products require fewer providers than do employer-sponsored plans of the same size.

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Question # 12

The following statements describe two types of HMOs:

The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.

The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.

Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.

Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:

The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.

The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.

The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

A.

Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.

B.

Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.

C.

Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.

D.

All of the above statements are correct.

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Question # 13

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

A.

ERISA applies to all issuers of health insurance products, such as HMOs

B.

pension plans and employee welfare plans are exempt from any regulation under ERISA

C.

ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans

D.

the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

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Question # 14

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

A.

Receives financial assistance from the federal government but not a state government.

B.

Is at a higher risk of operating at a loss than are most other hospitals.

C.

Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.

D.

Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

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Question # 15

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

A.

Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.

B.

Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.

C.

Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.

D.

Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

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Question # 16

Medicaid is a joint federal and state program that provides healthcare coverage for low-income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

A.

Federal government is responsible for making all claim payments

B.

Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries

C.

State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement

D.

State governments are responsible for establishing overall regulation of the Medicaid program

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Question # 17

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.

The provider network that Shipwright uses to furnish services for its workers’ compensation program will most likely

A.

Emphasize primary care and consist mostly of generalists

B.

Focus treatment approaches on rapid recovery rather than cost

C.

Offer workers’ compensation beneficiaries the same types and levels of treatment that Shipwright’s traditional network furnishes to group health plan members

D.

Exempt participating providers from meeting standard credentialing requirements

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Question # 18

Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs

A.

are reimbursed solely through Medicaid programs

B.

provide extensive long-term care

C.

are reimbursed on a fee-for-service basis

D.

limit benefits to a specified maximum amount

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Question # 19

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

A.

$200

B.

$1,000

C.

$1,800

D.

$9,000

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Question # 20

In most states, workers’ compensation is first-dollar and last-dollar coverage, which means that workers’ compensation programs

A.

Can place limits on the benefits they will pay for a given claim

B.

Can deny coverage for work-related illness or injury if the employer is not at fault

C.

Must pay 100% of work-related medical and disability expenses

D.

Can hold employers liable for additional amounts that result from court decisions

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Question # 21

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis-related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

A.

typically allow for the assignment of multiple classifications for an outpatient visit

B.

always apply to a patient's entire hospital stay

C.

typically serve as a payment system for inpatient services

D.

typically include reimbursements for professional fees

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Question # 22

One true statement about the Medicaid program in the United States is that:

A.

The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs

B.

Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30

C.

The individual states have responsibility for administering the Medicaid program

D.

Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

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Question # 23

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists:

Cheryl Stovall, who is currently in the process of completing a residency in her field of specialization.

Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency.

Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field.

Ventnor's requirement of board certification is met by:

A.

Cheryl Stovall, Thomas Kalil, and Roger Todd.

B.

Thomas Kalil and Roger Todd only.

C.

Thomas Kalil only.

D.

None of these individuals.

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Question # 24

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

A.

Require access to greater numbers of obstetricians and pediatricians

B.

Have stronger relationships with primary care providers

C.

Are less reliant on emergency rooms as a source of first-line care

D.

Need fewer support and ancillary services

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Question # 25

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

A.

In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.

B.

Typically, case managers for workers' compensation programs are physical therapists.

C.

Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.

D.

Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

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Question # 26

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

A.

include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan

B.

hold that the responsibility of the provider to deliver services is usually subject to the provider's receipt of information regarding the eligibility of the member

C.

contain a gag clause or a gag rule

D.

include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

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Question # 27

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

A.

limit the size of its network to the number of providers necessary to meet the needs of its enrollees

B.

require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate

C.

refuse payment to non-network providers who submit claims for Medicare-covered expenses

D.

shift all risk for Medicare-covered services to network providers

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Question # 28

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

A.

It is maintained by the individual states

B.

It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States

C.

The information in the NPDB is available to the general public

D.

It was established to identify and discipline medical practitioners who act unprofessionally

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Question # 29

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

A.

Two measures of BH quality are patient satisfaction and clinical outcomes assessments.

B.

For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care.

C.

In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management.

D.

Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis.

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Question # 30

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

A.

Acase mix/severity adjustment

B.

An external performance standard

C.

Structural measures

D.

Behavior modification

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Question # 31

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

A.

Managed dental care is federally regulated.

B.

Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.

C.

Currently, there are no nationally recognized standards for quality in managed dental care.

D.

Processes for selecting dental care providers vary greatly according to state regulations on managed dental care networks and the health plan’s standards.

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Question # 32

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

A.

All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider.

B.

According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider’s receipt of information regarding the member’s eligibility for these services.

C.

Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member’s health plan.

D.

Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

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Question # 33

Federal laws—including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act—have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:

Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.

Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.

From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

A.

Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973

B.

Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act

C.

Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act

D.

Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

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Question # 34

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier’s electrocardiogram were transmitted using a communications system known as

A.

Anarrow network

B.

An integrated healthcare delivery system

C.

Telemedicine

D.

Customized networking

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Question # 35

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

A.

Purpose of the agreement

B.

Manner in which the provider is to bill for services

C.

Definitions of key terms to be used in the contract

D.

Rate at which the provider will be compensated

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Question # 36

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.

One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

A.

authorization

B.

provider relations

C.

credentialing

D.

utilization management

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Question # 37

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

A.

has a legal right to access a prospective provider’s confidential medical records at any time

B.

must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day

C.

is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number

D.

must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

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Question # 38

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

A.

Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates Dr. Quill’s contract without cause

B.

Requires that Regal must base its decision to terminate Dr. Quill’s contract on clinical criteria only

C.

Allows either Regal or Dr. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process

D.

Allows Regal to terminate Dr. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

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Question # 39

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

A.

Areduction in the rate of growth in health plan premium levels

B.

Areduction in the level of outcomes management and improvement

C.

An increase in the rate of inpatient hospital utilization

D.

All of the above

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Question # 40

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

A.

Require a medical examination prior to accepting an application for employment

B.

Include in the employment application questions pertaining to health status

C.

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

D.

Require applicants to answer questions pertaining to the use of drugs and alcohol

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Question # 41

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

A.

Most-favored- nation arrangement

B.

Alimit on action

C.

Aconsideration

D.

An assignment

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Question # 42

An health plan enters into a professional services capitation arrangement whenever the health plan

A.

Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patient’s care

B.

Pays individual specialists to provide only radiology services to all plan members

C.

Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patient’s medical expenses

D.

Contracts with a primary care provider to cover primary care services only

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Question # 43

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered “medically necessary.” Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a member’s illness or injury must be

A.

Consistent with the symptoms of diagnosis

B.

Furnished in the least intensive type of medical care setting required by the member’s condition

C.

In compliance with the standards of good medical practice

D.

All of the above

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Question # 44

Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.

A.

both the general eye examination and the prescription for corrective lenses

B.

the general eye examination only

C.

the prescription for corrective lenses only

D.

neither the general eye examination nor the prescription for corrective lenses

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Question # 45

Decide whether the following statement is true or false:

The organizational structure of a health plan’s network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.

A.

True

B.

False

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Question # 46

The Athena Medical Group has purchased from the Corinthian Insurance Company individual stop-loss insurance coverage for primary and specialty care services with a $5,000 attachment point and 10 percent coinsurance. One of Athena’s patients accrued $8,000 of medical costs for primary and specialty care treatment. In this situation, Athena will be responsible for paying an amount equal to

A.

$300, and Corinthian is obligated to reimburse Athena in the amount of $2,700

B.

$2,700, and Corinthian is obligated to reimburse Athena in the amount of $5,300

C.

$5,300, and Corinthian is obligated to reimburse Athena in the amount of $2,700

D.

$7,700, and Corinthian is obligated to reimburse Athena in the amount of $300

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Question # 47

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

A.

Wrap-around payment system

B.

Relative value scale (RVS) payment system

C.

Resource-based relative value scale (RBRVS) system

D.

Capped fee system

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Question # 48

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

A.

One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.

B.

One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.

C.

A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.

D.

A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

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Question # 49

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

A.

$42,857

B.

$56,700

C.

$272,160

D.

$680,400

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Question # 50

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.

A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members’ prescription drugs than it would if it did not use a formulary.

A.

closed / higher

B.

closed / lower

C.

open / higher

D.

open / lower

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Question # 51

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.

If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

A.

Daily medical care and monitoring

B.

Regular rehabilitative therapy

C.

Respiratory therapy

D.

All of the above

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Question # 52

From the following answer choices, choose the type of clause or provision described in this situation.

The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

A.

Cure provision

B.

Hold-harmless provision

C.

Evergreen clause

D.

Exculpation clause

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Question # 53

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market’s existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:

Question 1: What are the cost-containment strategies of the health plans with increasing market shares?

Question 2: What are the premium strategies of the health plans with large market shares?

Question 3: What are the characteristics of health plans that are losing market share?

In its competitive analysis, Holiday should most likely obtain answers to questions

A.

1, 2, and 3

B.

1 and 2 only

C.

1 and 3 only

D.

2 and 3 only

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Question # 54

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

A.

Slower access to BH care for plan members

B.

Increased collaboration between BH providers and PCPs

C.

Fewer specialized BH services for plan members

D.

Decreased continuity of BH care for plan members

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Question # 55

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

A.

Compared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.

B.

In urban areas, limiting the number of specialists on a panel usually affects the network’s market appeal more than does limiting the number of primary care physicians.

C.

The greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.

D.

Typically, hospital contracting is easier in urban areas than in rural areas.

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Question # 56

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

A.

Dr. Kwan most likely was required to seek authorization from Poplar before performing this particular service.

B.

Dr. Kwan most likely was paid on a FFS basis for providing this service.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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Question # 57

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.

Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.

Autumn’s method of reimbursing specialty providers can best be described as a

A.

Disease-specific arrangement

B.

Contact capitation arrangement

C.

Risk adjustment arrangement

D.

Withhold arrangement

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Question # 58

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s

A.

Premium rates

B.

Ability to monitor utilization

C.

Number of primary care providers (PCPs)

D.

Number of specialists and ancillary providers

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Question # 59

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

A.

Require Dr. Barlow and Amity to use arbitration to resolve any disputes regarding the contract

B.

Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters

C.

Require Dr. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract

D.

State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between Dr. Barlow and Amity

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Question # 60

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

A.

Agree not to sue or file claims against an Octagon plan member for covered services

B.

Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions

C.

Maintain the confidentiality of the health plan’s proprietary information

D.

Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

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